A client is experiencing sickle cell crisis precipitated by a right lower lobe pneumonia. The vital signs are: HR-110/min: RR-28; B/P-96/54: T-100.8 PO: Pulse Oximetry-96%. What is the best nursing action?

Maintain IV fluid infusion and assess adequacy of hydration

Provide continuous sedation for pain relief

Insert an indwelling (Foley) catheter and monitor hourly urinary output

Prepare for endotracheal intubation and ventilatory support

Answer and Explanation

The Correct Answer is A

A) Maintain IV fluid infusion and assess adequacy of hydration: This is the best nursing action as adequate hydration is crucial in managing sickle cell crisis. It helps to reduce blood viscosity and prevent further sickling of red blood cells, which is especially important in the context of pneumonia, as dehydration can exacerbate the crisis.

B) Provide continuous sedation for pain relief: While managing pain is essential, continuous sedation is not the most appropriate first step in this situation. Pain management should be addressed, but hydration and treating the underlying causes (like pneumonia) take priority.

C) Insert an indwelling (Foley) catheter and monitor hourly urinary output: While monitoring urinary output can be important, it is not the most immediate action in this case. Focus should be on hydration and addressing the sickle cell crisis rather than on urinary output at this time.

D) Prepare for endotracheal intubation and ventilatory support: Although respiratory distress is a concern with pneumonia, the current pulse oximetry reading of 96% indicates adequate oxygenation at this time. Preparing for intubation should not be the first action unless the patient shows signs of respiratory failure or severe distress.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is D

Explanation

A. The layers of your heart are weak and thin: This statement does not accurately address the underlying cause of chest pain in coronary artery disease. Weakness in heart layers is not a common explanation for angina.
B. The pain you have is because your heart valves are damaged: While valve damage can lead to cardiac symptoms, it is not the primary cause of chest pain associated with coronary artery disease, which is more directly related to blood flow issues.

C. Your heart muscle is weak and is not pumping forcefully: This statement could be true in the context of heart failure but does not specifically explain the chest pain associated with coronary artery disease.

D. The pain is caused by decreased oxygen to the heart muscle: This is the most accurate and appropriate response. Chest pain in coronary artery disease, often referred to as angina, typically occurs due to reduced blood flow and, consequently, oxygen delivery to the heart muscle. This explanation helps the client understand the physiological basis of their symptoms.

A. Depending on the client's age, the findings may be normal B. A blood clot may be forming and the client needs immediate intervention C. Decreased oxygen to the tissues causes changes in hair growth and nail texture D. Decreased hair is most likely a hereditary condition and naill changes are related to fungus

Correct Answer is C

Explanation

A) Depending on the client's age, the findings may be normal: While changes in hair growth and nail texture can occur with aging, the specific combination of hair loss on the legs and thick toenails in a client with peripheral vascular disease is indicative of underlying circulatory issues rather than simply a normal aging process.

B) A blood clot may be forming and the client needs immediate intervention: While peripheral vascular disease does increase the risk of blood clots, the presence of no hair on the legs and thick toenails is more directly related to chronic insufficient blood flow rather than an acute clotting situation requiring immediate intervention.

C) Decreased oxygen to the tissues causes changes in hair growth and nail texture: This statement accurately describes the physiological changes occurring in peripheral vascular disease. Reduced blood flow and oxygen delivery to the lower extremities result in hair loss and thickened nails, as hair follicles and nail growth depend on adequate perfusion.

D) Decreased hair is most likely a hereditary condition and nail changes are related to fungus: While hereditary factors can influence hair loss and fungal infections can affect nails, in the context of peripheral vascular disease, the findings are primarily due to inadequate blood supply rather than hereditary issues or fungal infections.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A client is experiencing sickle cell crisis precipitated by a right lower lobe pneumonia. The vital signs are: HR-110/min: RR-28; B/P-96/54: T-100.8 PO: Pulse Oximetry-96%. What is the best nursing action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The client with coronary artery disease asks the nurse. "Why do I get this chest pain?" Which would be the most appropriate response?

Correct Answer is D

Explanation

The nurse, who is assessing a client with peripheral vascular disease, notes that the client has no hair on the legs and has thick toenails. Which statement best describes the cause of this finding?

Correct Answer is C

Explanation

The client, who is scheduled for a nuclear stress test, tells the nurse that the breakfast tray was not delivered and complains of hunger. Which of the following statements represent the nurse's best response?

The nurse is administering Furosemide 40 mg PO to a client with peripheral edema. Which method should the nurse use to best evaluate the client's response to this medication?

The nurse is reviewing the laboratory data of a client diagnosed with coronary artery disease. Which set of laboratory results indicates a need for client teaching regarding dietary modifications?

The nurse is assisting a client diagnosed with hypertension with menu selection. Which items should the nurse suggest?

The nurse, who is caring for a client diagnosed with coronary artery disease, prioritizes the problem of impaired Tissue Perfusion into the plan of care. Which expected outcome would be most appropriate? The client will:

A client is ordered to receive a bolus of 200 mL of NSS in 25 minutes. At what rate should the nurse set the IV pump?

The nurse is conducting dietary teaching for a client diagnosed with coronary artery disease. Which statement made by the client indicates an understanding of fat sources and the need to limit saturated fats?

A client who has chronic stable angina is being discharged. Which statement by the client indicates an understanding of the discharge teaching?